<link rel="stylesheet" type="text/css" href="/templets/breastPhone/css/form.css">
<script type="text/javascript" src="/templets/breastPhone/js/form_submit.js"></script>
<div class="online_div">
		<div class="title_div">
			<img class="title_icon" src="/templets/breastPhone/images/team_icon.png">
			<div class="title_word">预约挂号</div>
			<a href="/a/yuyueguahao"><img class="more_icon" src="/templets/breastPhone/images/more_icon.png"></a>
		</div>
		<div class="form_div">
			<form id="myform" action="http://mail.jszjrzk.com/breast/phone" method="post">
				<div class="first_label">
					您的姓名：
				</div>
				<div class="first_input">
					<input type="text" name="name" id="name" placeholder="请输入您的真实姓名">
				</div>
				<div class="second_label">
					联系电话：
				</div>
				<div class="second_input">
					<input type="text" name="phone" id="phone" placeholder="请输入您的电话号码">
				</div>
				<div class="third_label">
					预约病种：
				</div>
				<div class="third_input">
					<select id="entity" name="entity">
						<option>--请选择病种--</option>
						<option value="乳腺增生">乳腺增生</option>
						<option value="乳腺纤维瘤">乳腺纤维瘤</option>
						<option value="乳腺囊肿">乳腺囊肿</option>
						<option value="乳腺炎">乳腺炎</option>
						<option value="乳腺结核">乳腺结核</option>
						<option value="乳腺真菌病">乳腺真菌病</option>
						<option value="乳房湿疹">乳房湿疹</option>
						<option value="检查">检查</option>
						<option value="未知">未知</option>
					</select>				
				</div>
				<div class="fourth_label">
					预约日期：
				</div>
				<div class="fourth_input">
					<input type="date" name="date" id="date">					
				</div>
				<div class="btn_box_div">
					<div id="reset_btn" class="reset_btn">
						<img src="/templets/breastPhone/images/xqing_18.jpg">
						清除重置
					</div>
					<div id="sub_btn" class="sub_btn">
						<img src="/templets/breastPhone/images/xqing_15.jpg">
						加密提交
					</div>
				</div>
			</form>
		</div>
	</div>